- Humana (Honolulu, HI)
- …a part of our caring community and help us put health first** The Corporate Medical Director relies on medical background and reviews health claims. The ... Corporate Medical Director works on problems of diverse scope and complexity...experience + Knowledge of the managed care industry including Medicare , Medicaid and or Commercial products + Possess analysis… more
- Sanford Health (Sioux Falls, SD)
- …and grievances processing. Collaborate with legal, compliance, operations, and medical management teams to address complex cases and ensure proper resolution. ... complaints, and grievance processes across all product lines, including ACA, Commercial, Medicare Advantage, Medicaid, DSNP, and ISNP. This role ensures adherence to… more
- UCLA Health (Los Angeles, CA)
- …Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Medical Director , Clinical Operations to help shape the future of our plan. ... In this key leadership role, you'll work closely with the Medical Director , Department of Health Services and play a vital part in scaling Health Services… more
- Pine Acres Rehabilitation & Care Center (Nebraska City, NE)
- …Services Director will assist residents in voicing and obtaining resolution to grievances . The Director will review complaints and grievances made by ... SOCIAL SERVICES/ADMISSIONS DIRECTOR JOB DESCRIPTION Department Social Services Reports to...actions and interactions are adequately documented in each resident's medical record, and that legal, ethical, and professional standards… more
- Dignity Health (Bakersfield, CA)
- …to the Medical Director of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other related ... offices, primarily in the Bakersfield/Central CA region.** **Position Summary:** The Medical Director of Physician Engagement is responsible for developing… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare -Medicaid Plan) * Develop and lead clinical strategy and objectives for… more
- Trinity Health (West Springfield, MA)
- …The Director , Quality Improvement and Compliance, in collaboration with the Medical Director , is responsible for developing and implementing the annual QI ... implement the annual Quality Improvement (QI) Plan with the Medical Director + In conjunction with ...compliance with CMS regulations. Has overall responsibility for the Medicare Part D fraud, waste and abuse Compliance Program.… more
- Commonwealth Care Alliance (Boston, MA)
- 011230 CA-Provider Engagement & Performance Position Summary: The Director of Provider Relations leads the strategic vision and operational execution of provider ... network performance, and ensuring compliance with regulatory standards. The Director drives initiatives that enhance operational engagement, member access, provider… more
- Molina Healthcare (NM)
- …corrective actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * Attends or chairs ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...leadership and quality improvement teams. * Facilitates conformance to Medicare , Medicaid, NCQA and other regulatory requirements. * Reviews… more
- Sanford Health (Sioux Falls, SD)
- …Shifts **Job Schedule:** Full time **Weekly Hours:** 40.00 **Job Summary** The Director of Provider Network Contracting is responsible for maintaining and growing a ... resources to ensure compliance with applicable state/federal access requirements. The Director will negotiate reimbursement terms that are built on Sanford Health… more
- State of Colorado (Pueblo, CO)
- …This position ensures compliance with nondiscrimination policies and manages grievances related to discrimination. This position manages complaints, develops ... + Review of videos involving physical response, abuse allegations, and youth grievances (if applicable). Additional reviews as required by the Youth Center… more
- Fallon Health (Worcester, MA)
- …to be the leading provider of government-sponsored health insurance programs-including Medicare , Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- ... policies and procedures, and regulatory standards. The Member Appeals & Grievances Intake Administrator is responsible for triaging and assigning all incoming… more
- STG International (Milledgeville, GA)
- …Coordinate Pre-certification sand recertification in accordance with facility policies for Medicare Advantage and + commercial insurance payers. + Interpret the ... coding for accuracy. + Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. + Periodically… more
- State of Colorado (Pueblo, CO)
- …safe, secure, and therapeutic setting for patients with both psychiatric and medical issues. The services provided include evaluation and treatment for patients who ... to the State Board of Nursing (SBON), Centers for Medicare Services (CMS), The Joint Commission (TJC), Colorado Department...This position works under the direction of the Assistant Director of Nursing (ADON) + The NM coordinates staffing… more
- State of Colorado (Greeley, CO)
- …security/control functions, educational support services, daily programming, recreation, meals, medical referral and follow-up, and customer service. Responsible to ... ongoing professional development training (as available). Resolves informal staff grievances . Provide formal/informal performance feedback. Initiate progressive discipline, in… more
- Elevance Health (Columbus, OH)
- …records of denied services for medical necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external ... to either uphold or deny appeal and forwards to Medical Director for approval. + Ensures that...Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. +… more
- State of Colorado (Denver, CO)
- …the facility clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the ... up on recommendations made by those providers. Collaborates directly with the DYS Medical Director and/or other providers to determine referrals to other… more
- WMCHealth (Margaretville, NY)
- …+ Keep abreast of economic conditions/situations and recommend to the Activity Director adjustments in activity programs that assure the continued ability to provide ... forms, reports, etc., and submitting such to the Activity Director as required. + Committee Functions + Serve on,...before entering a resident's room. + Review complaints and grievances made by the resident and make a written/oral… more
- STG International (Milledgeville, GA)
- …interviewing, screening and onboarding new staff in key positions. Assist the Director of Human Resources and department directors to develop written job ... properly identified and recorded. Coordinate with the Administrator and the Director of Human Resources regarding issues involving labor laws, progressive discipline… more
- Cognizant (Salem, OR)
- …+ Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... Plan/Payer. The comprehensive process includes analyzing, reviewing, and processing medical necessity denials for resolution. You will be a... Medicare , Medicaid, and third-party guidelines. + Effectively document and… more